We Made New Hampshire Magazine’s ‘Top Doc’ List for 2015!

Posted on March 20, 2015.

We are proud to be included in New Hampshire Magazine’s Top Doctors for 2014!  Congratulations ... Read More

FREE Sports Physicals

Posted on February 17, 2015.

The Safe Sports Network free sports physical clinic will once again be held at our Bedford ... Read More

Tuesday, January 27th

Posted on January 26, 2015.

PLEASE BE ADVISED: Our offices will not be seeing patients tomorrow January 27th. We will ... Read More

New Hampshire Orthopaedic Center

Traveling After Joint Replacement: Questions Answered

Posted on March 23, 2015.

By: Kathleen A. Hogan, MD

When can I travel? Will my new hip replacement set off metal detectors at the airport? Can I get a card to prove that I had my knee replaced? These are common questions of patients are planning on traveling after joint replacement.

Security Screening When Traveling After Joint Replacement

Hip and knee replacements are made of metal and will be detected by most metal detectors at airports and other security screening stations. Prior to the terrorist attacks of 2001, airline screeners would accept a card or physician note stating that a metal implant had been placed and no additional screening was needed. That is no longer the case. The TSA will not accept any card as proof of a joint replacement. If a metal detector is set off, additional screening will be required.

The use of full body X-ray scanners at most airports in the United States has made travel much easier for the millions of travelers with metal implants. Although the metal implant will be picked up by the X-ray scanner, it will be clear that the metal is in the bone. Occasionally, a simple pat down of the body part is done, but the screening process is much less time consuming than it was previously. Additionally, people with pacemakers or other implanted electronic devices who used to have to bypass the metal detector and be screened by hand now can usually pass safely through the X-ray scanner.

Recommendations for Safely Traveling After Joint Replacement

It is safe to travel after a hip or knee replacement. If the surgery was done within the last 6 weeks, you should discuss with your surgeon if any particular treatment for the prevention of blood clots is recommended. Recent surgery is a risk factor for blood clots as is prolonged sitting, and dehydration; make sure to drink water on your flight. For flights longer than 4 hours in duration, I recommend getting out of your seat and moving around the aircraft every few hours. Compression stockings can help prevent swelling in your legs and decrease the risk of blood clots. Taking aspirin before and after a long flight may also decrease this risk. However, if you have had a prior blood clot, have a family history of blood clots, are taking birth control pills or hormone replacement medications, have had recent surgery or have cancer, you may be at much higher risk. Sometimes prescription anticoagulants are recommended for individuals at high risk of blood clots. If you have any concerns, be sure to talk to your doctor before your flight.

Most major airports are large and much walking is required to get from the terminal entrance to your gate. If you walk with a cane or walker or have cardiac or pulmonary problems that limit your ability to walk long distances, consider asking for wheelchair assistance. You do not need a physicians note to take advantage of this service. This can help you to arrive at your destination without being exhausted from airport travel.

I hope this article has answered many of your questions about traveling after joint replacement. Enjoy your trip and don’t forget to talk to your doctor before your trip if you have any concerns!

Why Weight Matters: Obesity and Knee Replacement

Posted on March 17, 2015.

By: Kathleen A. Hogan, MD

Obesity and knee replacement are closely linked. It is well established that people who are overweight have an increased incidence of knee arthritis at a younger age and are more likely to require knee replacement. Joint pain can limit mobility and diminish exercise tolerance which may contribute to weight gain.

What is BMI?

The relationship between height and weight is determined by a mathematical calculation to give a body mass index (BMI). A BMI of 20-25 is considered to be ideal. A person with a BMI above 30 is considered to be obese and over 40 is morbidly obese. For example, a 5’7’’ 145 lb woman would have a BMI of 23 (normal body weight). If her weight increased to 200 her BMI would be 31 (obese). At a weight of 250, her BMI would be 40 (morbidly obese). BMI helps physicians standardize our discussion of weight. However it does not take into account the distribution of that weight – the apple or pear shaped body shapes for example. Nor does it determine if weight is primarily muscle or fat.

Risks of Obesity and Knee Replacement

Why does weight matter when discussing joint replacement? Patients who are excessively overweight are at much higher risk of compilations following hip or knee replacement surgery. The risk of infection, for example rises exponentially as BMI increases over 40. The risk of a major infection after knee replacement is less than 1% in patients with a BMI of 20-25. This risk rises to 1-2% in obese patients (BMI >30), 3-4% in morbidly obese patients (BMI >40) and in a patient with a BMI of 50 the risk is over 8% This increased risk is independent of other medical problems such as diabetes, hypertension, and cardiac disease. Infection after a joint replacement can be a devastating problem. Often, the metal implants must be temporarily removed in order to eradicate the infection. Prolonged treatment with IV antibiotics is required. Only after the infection has been successfully treated can a new joint be put back in place. Elevated body weight also increases the risk of medial complications, blood clots, and even death following surgery. Diabetes, smoking, and poor nutrition are also risk factors for complications following surgery.

What Criteria Are Used?

Every surgeon has his or her criteria for determining if a patient is “too big” for a joint replacement. Body weight and BMI are important; however other heath problems such as diabetes, smoking, malnutrition, peripheral vascular disease, and the condition of the legs’ skin are also important considerations in determining if surgery can be safely performed. It is very difficult to explain to someone that their disabling arthritic pain can not be safely treated with a joint replacement because of their body weight. Joint replacement surgery can be a life altering procedure when successful, with improvement in mobility and elimination of pain. However, the complications of joint replacement can be devastating as well. If a surgeon tells you that weight loss is necessary prior to surgery, it is only because the risks of surgery outweigh the potential benefits. Loosing weight prior to knee replacement will not only improve the outcome of your surgery and lower the risk of major complications, but will also have life-long health benefits.

Causes of Lower Leg Pain: A Long List

Posted on .

By: William P. Rix, MD

Lower leg pain on the outside of the leg (lateral leg pain) is a common presenting complaint in the orthopedist’s office. Typically the pain is felt anywhere from the outside aspect of the knee to the lateral ankle. The patient usually gives a history of gradual onset of pain without preceding trauma. The differential diagnoses list is long and finding the exact cause can be challenging.

The spine, hip, pelvis, knee or lower leg can be the cause and within those anatomic structures the bone, joint, nerve, tendon, ligament, meniscus or muscle can be involved. When the lower leg pain is coming from an asymptomatic (painless) hip or low back we call it “referred” pain. The exact mechanism or physiology of referred pain is not completely understood.

Common Causes of Lower Leg Pain

Lumbar spine:

Degenerative arthritis of the disc space or facet joints
Lumbar radiculitis (a pinched nerve)
Spinal stenosis (narrowing of the spinal column)

Hip:

Degenerative changes in the hip joint
Trochanteric bursitis (inflammation of the abductor muscle tendon)
Stress or fragility fractures of the hip

Knee:

Tracking problems within patellofemoral (kneecap) joint
Degenerative arthritis in the lateral (outside) joint compartment
Tear of the lateral meniscus (cartilage of the knee)

Lower leg:

Stress or fragility fractures of the fibula, especially in people with osteoporosis.

For athletes, especially runners, the list must be expanded to include muscle compartment syndrome (swelling of a leg muscle in a restricted space), pinched nerves in the leg itself (as opposed to the low back), soft tissue (muscle, tendon, ligament or fascia) overuse syndromes, and foot and ankle malalignment problems.

Mention should be made of less common causes of lower leg pain such as peripheral vascular disease (poor blood supply to the legs) and reaction to some medications (e.g. statins).

Making the Diagnosis

The key to making the diagnosis is in the clues (the history, or what the patient tells the doctor) and the evidence (the objective findings on exam). In consultation, for example, if the patient tells the doctor the pain in the leg comes on while he/she is walking to the grocery store but goes away while leaning on the shopping cart, the orthopedist thinks immediately of lumbar stenosis; if the patient describes his/her lower leg pain as accompanied by “pins and needles” (paresthesia), then a pinched nerve is implicated, either in the low back (“referred”) or in the leg. (Note: while the absence of paresthesias does not rule out nerve involvement, its presence is a strong indicator of it.)

In physical examination, if the orthopedist can find a particular movement or maneuver that reproduces the patient’s pain, he is in luck because this narrows the diagnoses considerably. For example, if the patient experiences the lower leg pain on arching his back and tilting towards the painful leg, then painful facet joints in the lumbar spine are suspect; if stressing the hip in flexion and rotation causes the pain, then the hip joint or bone is implicated and likewise, a positive single leg squat test might point to an arthritic patellofemoral joint, while exquisite tenderness on palpation of the distal fibular bone would suggest a stress fracture.

X-rays, and to a lesser extent, MRIs are important diagnostic tools in our search for the diagnosis. X-rays detect arthritis, stress fractures, instability and malalignment. MRIs detect bone bruising, spinal stenosis, tendon/ligament injuries and meniscal tears in the knees.
Often, using any combination of clues, evidence and imaging, we can narrow the list of possible diagnoses down to two or three. At that point we will resort to diagnostic injections with local anesthetics to firm up the diagnosis. If the injection into a suspected pain generator removes or significantly reduces the lower leg pain, we have our diagnosis.

Now, specific treatment can begin.

Snowbirds

Posted on February 23, 2015.

By: Kathleen A. Hogan, MD

With the arrival of cold and snow, many people head south for warmer weather. One of the many reasons older people leave New Hampshire during the winter months is that their arthritic joints feel better in a warmer climate. Certainly, avoiding snow and ice can minimize your chance of falling and breaking bones. But does warmer weather really influence the pain from arthritic joints?

First, it is important to understand how arthritis causes pain. Arthritis refers to the loss of the normal cartilage that covers the ends of the bones. Instead of two smooth surfaces gliding past each other, they are now rough. Joint fluid coats the surfaces, providing lubrication. Arthritis causes pain because of the resulting inflammation, swelling, and loss of motion. So how does changes in climate affect these sources of pain?

Ice has been shown to decrease inflammation in joints, which is why icing is a commonly recommended treatment for arthritic joints. But, even when the air temperature is cold, your body acts to keep its internal temperatures relatively constant. Joints further away from the heart (fingers/toes) may become cold, but the body temperature at the knees and hip are relatively constant despite the cold air. Warmer climates do not necessarily decrease inflammation or swelling in your joints. The few studies that have been done on this topic have not found clear correlation between musculoskeletal pain and temperature.

However, cold air temperatures can make joints and muscles feel stiff and less limber. When the weather is unpleasant, people are naturally less likely to go outside and exercise. Joints that do not move become stiffer. Stiffness causes pain. This is probably the main reason arthritis pain feels better in transitioning to a warmer climate in the middle of winter.

If you are staying in New Hampshire this winter, you can mimic some of these effects seen in the warmer climates. Wear warm, compressive clothing around your painful joints to keep them from feeling stiff. Consider using a heating pad on sore joints to help warm them up prior to activities. Do not let the cold weather keep you from being active. Activity is beneficial to arthritic joints!

When you are outdoors this winter, make sure to be wary of ice. Falls are a frequent occurrence in the winter and if your bones are osteoporotic, even a small slip can result in a broken wrist or hip. Wear sensible shoes, pay attention to where you are walking, make sure you de-ice walkways and stairs outside your home. Canes can slip on the ice and water as well. Four prong canes and walkers are slightly more steady. Be particularly careful if you have broken a bone before; prior fractures are often a sign that your bones are fragile and prone to breaking.

Outpatient Joint Replacement?

Posted on January 3, 2015.

By: Kathleen A. Hogan, MD

When knee and hip replacements were first developed, most patients would stay in the hospital for a minimum of a week, sometimes longer. This lengthy hospital stay was felt to be necessary for patients to get the physical therapy and care they required for full recovery. Today, many patients remain in the hospital for two or three nights after joint replacement. But why? Certainly if a patient has diabetes, cardiac disease, kidney problems, sleep apnea or COPD it is important to be monitored closely for the first few days after surgery to ensure that there are no medical complications following surgery. But what about someone without any of these medical problems? Do they need to stay in the hospital just for physical therapy? In the hospital, physical therapists work with joint replacement patients only once or twice a day. This could certainly be done at home.

But what’s wrong with staying at the hospital for a few days? Many people prefer the comforts of home to the sterile conditions of a hospital. While at the hospital, you may be exposed to patients who are sick with the flu or other illnesses. Bacteria found in hospitals is often resistant to many antibiotics. Nurses wake you up to check on you at night and control when you receive medication. Nurses will take care of several patients and may not be available immediately. Most common post-operative problems such as swelling, wound drainage, and blood clots can be managed by your surgeon in the office if they occur. Hospital care is also very expensive; hospital and implant costs make up the majority of your bill.

Hip and knee replacements can be painful. Improved pain control with the use of long lasting nerve blocks, multimodal pain management, and intra-articular injections can reduce that pain to a manageable level with oral narcotics. Rotator cuff repair and ACL reconstruction are also painful procedures that used to require a short stay in the hospital but are now outpatient surgeries.

Outpatient hip and knee surgeries are performed at a surgical center, not at the hospital. Patients stay overnight for observation and go home the next morning. Nurses teach patients how to use crutches or a walker. One nurse is assigned to a maximum of two patients. Physical therapists visit patients at home until they can travel to a therapy office. The surgeon is available for the patient to call if there are any questions or problems at home.

Not every patient is a candidate for an outpatient hip or knee replacement. However there is no need for lengthy hospital stays for healthy patients after joint replacement. For carefully selected patients, home can be a safer and more comfortable place to recover after surgery than the hospital.